Card Set Information
Therapeutics - Headaches
Name 3 types of primary headaches and one secondary type.
1. Migraines (with or without aura)
What diagnostic clues indicate that a headache is of vascular origin (migraine)?
Pulsatile, pounding, throbbing (changes in intensity)
What diagnostic clues indicate a headache is a tension headache?
Constant tight pressure, "hatband" distribution, NOT pounding
What diagnostic clues may indicate a headache is d/t a tumor?
Steady aching pain, may have acute onset
What type of headache may present as sudden severe pain, possibly described as the "worst headache of my life"?
Do migraine headaches count as a disability?
They do count as an impairment according to the EEOC, so if the migraines limit any major life activities of the patient, then yes, they'd be considered a disability under the ADA.
What are the diagnostic criteria for migraines?
More than 5 episodes of headache lasting from 4 to 72 hours with at least 2 of the following:
moderate or severe intensity
aggravation by or avoidance of routine physical activity
AND, during HA, at least 1 of the following:
nausea, vomiting, or both
photophobia and phonophobia
What part of the brain is thought to be responsible for the pain of migraines?
Neurotransmitters involved in the pathophys of migraines
GABA (GABA agonist may prevent HA)
NMDA (stimulation by glutamate, aspartate may lead to HA)
Calcitonin gene-receptor peptide
name some chemical migraine triggers
name some drug triggers for migraines
Others/stimulants/substances (bactrim, caffeine withdrawal, tobacco)
name some non-chemical stimuli that may be migraine triggers
physical factors (bright lights, weather changes, physical activity)
psychological factors (stress)
lifestyle triggers (fasting, over/under sleeping)
metabolic triggers (hypoglycemia)
Name 2 preheadache phases the patient might experience
Premonitory symptoms (neurologic, psychologic, other)
Features of the aura
Most common is visual (positive sx: photopsia, scintillations, teichopsia -
)(negative sx: scotoma, hemianopsia -
interruptions in visual field
Sensory/motor features (parasthesias, dysphasia/aphasia, weakness)
Do all patients with migraines have an aura?
No - only about 30%
How long before the HA starts does one usually experience an aura?
about 5-20 minutes
How long do migraines usually last?
Clinical features of the HA phase
unilateral/bilateral throbbing pain in frontotemporal region
GI sx (nausea in 90%, vomiting in 33%)
phono- and photo- phobias
systemic sx (nasal congestion, diaphoresis, periorbital edema)
Describe the resolution phase
Also called postdromal
May last 1-2 days
Fatigue, irritability, weakness, euphoria, scalp tenderness, anorexia
What are the phases of migraine clinical presentation?
1. preheadache phases
2. headache phase
3. resolution phase
What class of drugs are DOC for moderate to severe migraines when simple analgesics or NSAIDS have failed?
Triptans - serotonin receptor agonists
What is the next step if pt fails to respond to one triptan?
Try a different triptan
Which triptan is now generic?
Do we generally see rebound HA with triptan treatment?
MOA of serotonin agonists
vasoconstriction of intracranial blood vessels
inhibition of vasoactive neuropeptide release
block trigeminal nuclei pain signal transmission
Dizziness, somnolence, fatigue
Parasthesias, tingling sensations, burning or warm sensations, flushing
Transient increases in BP
Chest symptoms (worst with SQ sumatriptan)
pain, pressure, heaviness in chest, neck, jaw
CI for triptan use
Hx of CVAs
DIs with triptans
MAOIs (wait at least 2 weeks in between)
Propranolol (decreases triptan metabolism)
Other serotonergic drugs (ADs, buspirone, selegiline, dextromethorphan, lithium, cocaine)
Use of ergot or another triptain within 24 hours
Name some triptans
Which triptans have a fast onset?
which triptans have a slow onset and long duration?
Which triptan has an active metabolite that is 2-6 times more potent than the parent?
What is a big issue with tolerance of ergot alkaloids?
Nausea/GI SEs (use with antiemetics)
SEs of ergot alkaloids
Peripheral vascular effects ( leg cramps, tingling, numbness in extremities)
Claudication (impaired circulation)
Ergotism (severe vasoconstrictive crisis)
CNS SEs (sedation, depression, fatigue)
: rhinitis, nasal congestion, taste disturbances
Cardiac effects (
ergots change the blood vessels
) - chest pain, heart valve probs
Cautions with ergot alkaloids
Pregnancy category X
Use in pts >60 not recommended
DIs with ergot alkaloids
Triptan use within 24 hours
Other serotonergic agents
CYP 450 3A4 inhibitors (antifungals, macrolides, etc)
name 2 ergot alkaloid agents
1. Ergotamine tartrate
2. Dihydroergotamine mesylate
What medication is commonly given with ergot alkaloids to counter gastric stasis and GI SEs?
How well are ergot alkaloids absorbed orally?
Poorly - extensive first pass effect
When might we use IV valproic acid in migraine patients? How fast is the onset?
Refractory patients or if they have CIs to triptans or ergots
Onset: 8-15 minutes
Why do we use metoclopramide in migraine patients?
to prevent gastric stasis and improve oral absorption of other abortive agents
effective antiemetic - give 15-30 minutes before analgesic
Used with NSAIDS, simple analgesics, ergots
Why/when would phenothiazines, buryrophenones be used in migraine tx?
For sedative and antiemetic properties (concurrently with other agents)
2nd or 3rd line agents for pts intolerant to ergots and triptans
When using phenothiazines, butyrophenones what must we monitor?
MOA of phenothiazines or butyrophenones
may involve sedative properties or dopamine antagonist activity
Example of phenothiazines or butyrophenones
Other abortive therapies
Calcium channel blockers
skeletal muscle relaxants
combos (NSAIDS and triptans, DHE and prochlorperazine)
Calcitonin gene-related peptide receptor antagonist (telcagepant - efficacy similar to zolmitriptan)
What type of surgery might be available to help migraines?
deactivation of peripheral migraine trigger sites
What is status migrainosus?
headache lasting >72 hours despite treatment - refractory to usual treatments
Features of status migrainosus
persistant, severe head, neck or face pain, GI symptoms, insomnia
Withdrawal of what medications is often associated with status migrainosus?
How is status migrainosus treated?
DHE or triptans
IV fluids (if N/V has induced dehydration)
Preventative/prophylactic treatment of migraines - goal
decrease the frequency of migraines
decrease the severity
decrease the duration
How often should patients take preventative treatment medications and for how long?
Daily for 3-12 months
How should preventative migraine treatments be started?
periodically re-evaluated for efficacy
Indications for preventative migraine treatment
excessive use of abortive meds (weekly or greater)
2+ migraines per month, >48 hour duration, severe intensity
ineffective or CIs to abortive therapy
How do we select a preventative treatment medication?
Based on comorbidities, DIs, cost
How long is an appropriate trial of a preventative med before declaring failure?
2-3 months minimum
Agents used for prophylactic treatment of migraines
Calcium Channel Blockers
NSAIDS (naprosyn for menstrual migraine prophyl)
Which triptan would be the best choice in pregnancy?
They are all Class C, but sumatriptan doesn't appear to be assoc with birth defects
Should preventative migraine therapy be used in pregnant women?
Why avoid NSAIDs in 3rd trimester?
premature closure of ductus arteriosis
Definition of menstrually related migraine headache
migraine without aura
occur on day -2 to +3 of menstruation
Treatment of menstrually related migraines
Symptomatic therapy: triptans
(best appear to be sumatriptan and rizatriptan)
, mefenamic acid
Short-term prevention taken perimenstrually: percutaneous estradiol, frovatriptan, naratriptan
What is the DOC for acute treatment of migraines in children
What is the 2nd line treatment for migraines in children?
What is a med that should be considered for acute treatment of migraine in adolescents?
Sumatriptan nasal spray
(3rd line for children?)
Options for preventative therapy of migraine in children and adolescents
Flunarizine (but not avail in US)
Cyproheptadine (also anti-itch)
(most are level U treatments)
Tension headache definition
At least 10 episodes where:
- HA lasts from 30 min to 7d
- HA has at least 2 of the following
: bilateral location, pressing/tightening quality, mild or moderate severity - not severe, not aggravated by routine physical activity
- Both of the following
: no N/V, no more than one episode of photophobia of phonophobia
What does educational level have to do with tension headaches?
The higher education level one has, the more likely one is to experience tension headaches
Acute treatment for tension headaches
other NSAIDs > APAP (limit to 2-3 days/week or can lead to analgesic rebound HAs)
preventative treatment for tension headaches
(ssri, botulism toxin - no effect!)
Features of cluster headache ("suicide headache")
cluster lasting 4-8 weeks 1-3 times per year
intense piercing-throbbing pain
up to 8 times a day (often nocturnal)
relatively short (15-180 min)
frequently occur 1-2 hours after falling asleep or in early morning
accompanied by autonomic sx (tearing, rhinorrhea)
pts are restless and prefer to pace or rock back and forth
pts tend to become aggressive
Ipsilateral autonomic symptoms
increased blood flow to skin
Acute treatment for cluster headaches
100% oxygen (60% respond within 20-30 minutes)
preventative pharmacotherapy for cluster headaches
during the cluster period:
Types of Chronic Daily HeadAche
transformed migraine (mixed sx of tension and migraine)
Overuse of Acute HA medication
Chronic tension-type HA
Paroxysmal hemicrania (identical to clusters, but more often and briefer attacks)(responsive to indomethacin)
risk factors for CDHA
hx of more than 1 HA per week
medication overuse (>10 days per month)
What is a medication overuse headache?
HA caused or perpetuated by acute headache relief meds
Definition of overuse (in the context of med-overuse HAs)
regular overuse of a HA med for > 3 mo
use of ergots, triptans, opioids or combo analgesics > 10 days per month
Use of simple analgesics >/= 15 d per month
Total use of all HA meds >/= 15 d per month